*** Note that the map above still shows Virginia and Maine as non-expansion states. Virginia lawmakers have passed Medicaid expansion, but it won’t take effect until 2019. And Maine voters have approved Medicaid expansion (it was supposed to take effect July 2) but the Governor is resisting the expansion process and there is an ongoing legal battle over the implementation of Medicaid expansion in Maine.***
State changes ahead for Medicaid
- Since 2010, 32 states have accepted federal funding to expand Medicaid under the ACA.
- Maine approved a ballot initiative in 2017 to expand Medicaid. Utah, Idaho, Montana, and Nebraska will have measures on the 2018 ballot.
- In 2018, Virginia lawmakers approved Medicaid expansion, which will take effect January 2019.
- Four states have received federal approval for Medicaid work requirements. Several others have pending waivers or are considering submitting waivers.
- Some states are attempting to change Medicaid by implementing lifetime caps on coverage, or by adjusting eligibility requirements.
- A handful of states have been exploring Medicaid buy-in programs.
- Nineteen states have yet to take ACA’s Medicaid expansion, but Virginia and Maine are likely to do so by 2019, and Utah, Nebraska, and Idaho may join them.
- New Hampshire, Indiana, Pennsylvania, Alaska, Montana, and Louisiana have expanded their Medicaid programs since 2014. Virginia and Maine are expected to do so in 2019.
- The 19 states that haven’t expanded coverage are missing out on nearly $364 in federal funding if they continue to reject expansion.
- Public support for Medicaid expansion is strong, with 56 percent of the public in favor of expansion.
When the Affordable Care Act was enacted in 2010, Medicaid expansion was a cornerstone of lawmakers’ efforts to expand realistic access to healthcare to as many people as possible. The idea was that everyone with household incomes up to 133 percent of poverty (138 percent with the 5 percent income disregard) would be able to enroll in Medicaid.
Since 2010, the number of states that have accepted ACA’s Medicaid expansion has steadily grown – from just a handful by 2012 to 32 states as of April 2018. (Maine voters approved expansion in July 2018, but Gov. Paul LePage has yet to more forward with implementation, and the issue has triggered a legal battle in the state.)
And, while 19 states have yet to adopt the expansion, non-expansion states continue to debate expansion’s merits – and citizens in a handful of states are pushing expansion initiatives.
At the same time, there are a host of other Medicaid-related developments in the works across the country – both in expansion and non-expansion states – that promise to dramatically affect eligibility for and access to Medicaid benefits. Some states are moving toward changes that would put increased limits on Medicaid eligibility – such as work requirements and lifetime caps – while other states are considering legislation that would give currently ineligible residents a chance to buy-in.
Suffice it to say, there’s plenty of activity to monitor at the state level.
States to watch for Medicaid changes
Several states are considering various changes to their Medicaid systems in 2018. In some cases, lawmakers are considering expansion or directing the state to seek a federal waiver to change the way Medicaid eligibility is handled, and in other states, voters are seeking to expand Medicaid with a ballot initiative:
Medicaid expansion with a ballot initiative
Maine voters approved a ballot initiative in the 2017 election, calling for Medicaid expansion in Maine by July 2018. Governor Paul LePage has refused to move forward with implementation, so the process has been delayed. But the ballot initiative is binding in Maine, so expansion will happen, it’s just a matter of when.
Medicaid expansion will be on the ballots in three other states in 2018, and Montana voters will get to decide whether to continue Medicaid expansion in the state:
- Utah: More than enough signatures were gathered, and the measure will be on the ballot in November 2018.
- Idaho: More than enough signatures have been gathered, and the measure will be on the ballot in November 2018.
- Nebraska: More than enough signatures were gathered, and the measure will be on the ballot in November 2018.
- Montana: Medicaid is already expanded in Montana, but that will end in June 2019 unless it’s reauthorized. The ballot initiative is to generate funding, via a tobacco tax, to help pay for the state’s share of the cost of ongoing expansion.
Legislation to expand Medicaid
Lawmakers in the states that haven’t expanded Medicaid have continued to introduce legislation each year in an effort to expand coverage. In 2018, Virginia lawmakers have passed a budget that includes Medicaid expansion, effective in 2019. The measure will include a work requirement and premiums/cost-sharing for enrollees with income above the poverty level, but it’s expected to make coverage newly-available to 400,000 Virginia residents.
Medicaid work requirements
Requiring people to be working (or volunteering, in school, in job training, etc.) for at least a certain number of hours per week is an idea that tends to be popular with Republican lawmakers. Most people who receive Medicaid benefits are either already working or would be exempt from work requirements (due to being disabled, taking care of a minor child, pregnant, etc.), but the myth of the “welfare queen” (or king) persists, and Medicaid work requirements are seen by some as a solution to a perceived problem.
The federal Centers for Medicare and Medicaid Services (CMS) has to approve a Medicaid work requirement before a state can implement it. The Obama Administration did not allow any work requirements for Medicaid, but the Trump Administration is much more open to the idea. As of September 2018, four states had received federal approval for work requirements (although Kentucky’s has been blocked by a judge), and several others have pending waivers or are expected to submit waivers in the near future. You can click on the link for each state to learn more about the approved or proposed work requirements.
Work requirements for states that have expanded Medicaid:
- Kentucky (approved, was to be effective July 2018, but a federal judge halted the implementation of the work requirement in late June) — 80 hours per month
- Arkansas (approved, effective June 2018 for people age 30-49; people age 19-29 will have to comply as of 2019) — 80 hours per month
- Indiana (approved, phased in, starting in 2019) — 5 hours per week initially, increasing to 20 hours per week
- New Hampshire (approved, effective January 2019) — 100 hours per month
- Arizona (pending CMS approval) — 20 hours per week
- Ohio (pending CMS approval) — 20 hours per week
- Michigan (legislation enacted in June 2018; waiver will request 2020 effective date) — 80 hours per month (the legislation initially called for 29 hours per week of work/community engagement, but it was revised to 80 hours per month before the final bill passed)
- Virginia enacted a budget that calls for Medicaid expansion starting in January 2019, but also directs the state to seek federal permission for a work requirement. The work requirement would phase in, starting with 20 hours per month after a person has been enrolled for three months, and ramping up to 80 hours per month by the time the person has been enrolled for a year. The work requirement is also likely to be delayed up to two years after expansion takes effect.
Lawmakers in Louisiana considered several work requirement bills in 2018, but none were enacted.
Work requirements for states that have not expanded Medicaid:
Several states that have not expanded Medicaid are seeking federal permission to impose Medicaid work requirements, despite the fact that their Medicaid populations are comprised almost entirely of those who are disabled, elderly, or pregnant, as well as children. The Trump Administration has yet to grant work requirements in any of these states, and in May 2018, CMS Administrator, Seema Verma clarified that these states will have to clearly demonstrate how they plan to avoid situations in which people lose access to Medicaid as a result of the work requirement, and yet also do not have access to premium subsidies in the exchange. For the time being, the following non-expansion states are seeking federal permission to impose a Medicaid work requirement:
- Maine (pending CMS approval) — 20 hours per week. Medicaid expansion has been approved by voters in Maine, but not yet enacted
- Mississippi (pending CMS approval) — 20 hours per week
- South Dakota (pending CMS approval) — 80 hours per month
- North Carolina (pending CMS approval, but lawmakers would have to first approve the Carolina Cares legislation, which calls for expanded Medicaid with a work requirement; North Carolina has not proposed a work requirement for the currently-eligible Medicaid population)
- Wisconsin (pending CMS approval; fulfilling the work requirement would be necessary to avoid the proposed 48-month cap on Medicaid benefits) — 80 hours per month.
- Kansas (pending CMS approval) — 20 or 30 hours per week, depending on circumstances
- Utah (pending CMS approval for Primary Care Network population; proposed for modified expansion) 20 or 30 hours per week, depending on circumstances (aligned with TANF rules).
- Alabama (pending CMS approval) — 35 hours per week
- Tennessee (legislature passed a bill that directs the state to seek approval for a work requirement, using TANF or other federal funds to implement the work requirement) — number of hours is not specified in the legislation, but is likely to be set at 20 hours per week.
Other Medicaid proposals to watch
Five states are seeking CMS approval to implement lifetime caps for Medicaid coverage: Arizona, Kansas, Maine, Utah, and Wisconsin. Thus far, CMS has not approved this provision for any states, and has notified Kansas that the proposal for a lifetime Medicaid cap will be rejected.
The Trump Administration also rejected Arkansas’ proposal to cap Medicaid eligibility at 100 percent of the poverty level, instead of 138 percent. Massachusetts has a similar request pending CMS approval, and Utah enacted legislation in 2018 directing the state to seek approval to expand Medicaid only to those earning up to the poverty level.
And no states have received approval for an asset test for Medicaid, although some, including Maine, are seeking such approval.
Several states have received approval, however, to impose premiums on certain Medicaid populations, restrict retroactive eligibility, and require more eligibility redeterminations.
New Hampshire enacted legislation in 2018 that directs the state to drop the current private approach to Medicaid expansion (buying policies in the exchange for people eligible for expanded Medicaid) and switch to a Medicaid managed care program instead. The state submitted a waiver amendment proposal to CMS in August 2018, seeking permission to implement the changes.
Some states have also considered the possibility of seeking approval for a Medicaid buy-in program, under which people who aren’t eligible for Medicaid would be allowed to purchase Medicaid coverage. Nevada lawmakers passed legislation to do so in 2017, but the governor vetoed it. Lawmakers in Colorado, Maryland, and New Mexico considered legislation in 2018 that would direct the state to conduct a study on the feasibility and cost of a Medicaid buy-in program (ie, allowing people who aren’t eligible for Medicaid to purchase Medicaid coverage instead of private market coverage). Colorado lawmakers ultimately did not pass the bill, and neither did Maryland lawmakers. But New Mexico enacted legislation in early 2018 calling for a study on the costs and ramifications of a Medicaid buy-in program.
Minnesota lawmakers considered, but did not pass, a bill in 2017 that would have allowed people to buy into MinnesotaCare, the state’s Basic Health Program (similar to Medicaid, but for people with slightly higher income). This issue is being revisited in 2018, however, and Minnesota Governor Mark Dayton supports it. Thus far, Medicaid buy-in has not gained much traction. But Democrats have been warming to the idea of a public option or single payer system, and Medicaid buy-in would certainly be a step in that direction.
History of Medicaid expansion
As noted at the start of this summary, Medicaid was a cornerstone of ACA lawmakers’ efforts to expand access to healthcare. The idea was that everyone with household incomes up to 133 percent of the federal poverty level (FPL) would be able to enroll in Medicaid.
People above that threshold – but whose incomes didn’t exceed 400 percent of FPL – would be eligible for premium tax credits in the exchanges to make their coverage affordable. And although there are some exceptions, most people in the individual health insurance market with incomes above 400 percent of poverty are able to afford insurance even though they don’t qualify for subsidies.
(Regardless of income, people who get their insurance from an employer receive subsidies in the form of the employer’s contribution to their premiums – and their premiums are pre-tax).
Because Medicaid expansion was expected to be a given in every state, the law was written so that premium subsidies in the exchange are not available to people with incomes below the poverty level. They were supposed to have access to Medicaid instead.
19 states say ‘No’ to Medicaid expansion, but Virginia and Maine will soon be on the “yes” list.
Unfortunately for millions of uninsured Americans, in 2012 the Supreme Court ruled that states could not be penalized for opting out of Medicaid expansion. And 19 states have not yet expanded their programs. (Until late 2015, there were still 22 states that had not expanded Medicaid, but Montana began enrolling people in their newly expanded Medicaid program in November 2015, for coverage effective January 2016, Alaska‘s Medicaid expansion took effect in September 2015, and Louisiana‘s Medicaid expansion took effect in July 2016).
Maine is expected to expand Medicaid under the terms of the ballot initiative that voters passed in November 2017, but the governor’s refusal to submit an expansion proposal to the federal government has delayed the process. Originally, it was slated to take effect in July 2018, but a legal battle over the governor’s refusal to move forward with expansion is ongoing as of September 2018, and the issue may not be resolved until a new governor takes office in early 2019 (Maine’s Governor submitted a court-ordered Medicaid expansion proposal to CMS in September 2018, but urged CMS to reject the proposal due to a lack of funding). And Virginia enacted budget legislation to expand Medicaid in May 2018, with expansion effective in January 2019.
But as of September 2018, there are still 19 states (including Maine and Virginia) where Medicaid expansion has not taken effect.
As a result of the failure to expand coverage in 19 states, the Kaiser Family Foundation estimates there are 2,4 million people in the coverage gap across 18 of those states (although Wisconsin has not expanded Medicaid under the ACA, BadgerCare Medicaid is available for residents with incomes up to the poverty level, so there is no coverage gap in Wisconsin).
Being in the coverage gap means you have no realistic access to health insurance. These are people with incomes below the poverty level, so they are not eligible for subsidies in the exchange. But they are also not eligible for their state’s Medicaid program.
In many of the states that have not expanded Medicaid, low-income adults without dependent children are ineligible for Medicaid, regardless of how little they earn. For those who do have dependent children, the income limit for eligibility can be very low: In Alabama, parents with dependent children are only eligible for Medicaid if their income doesn’t exceed 18percent of the poverty level. For a family of three, that’s only $312 per month (and yet, Alabama wants to impose a work requirement on those parents who are currently eligible for coverage).
Although the 2.4 million people in the coverage gap can qualify for an exemption from the shared responsibility provision – and are thus not subject to the ACA’s penalty for not maintaining health insurance – that’s likely to be little consolation to those who want and need health insurance but are unable to obtain it because their state has rejected Medicaid expansion (the penalty for not having coverage is still in effect as of 2018; it will be repealed after the end of 2018, under the terms of the GOP tax bill that was enacted in late 2017).
More states easing into expansion
New Hampshire, Indiana, Pennsylvania, Alaska, Montana, and Louisiana all expanded their Medicaid programs since mid-2014. And Virginia lawmakers passed Medicaid expansion in a special legislative session in May 2018, albeit with a work requirement. Virginia’s Medicaid expansion will take effect in January 2019.
The first six states to implement Medicaid did so in 1966, although several states waited a full four years to do so. And Alaska and Arizona didn’t enact Medicaid until 1972 and 1982, respectively. Eventually, Medicaid was available in every state, but it certainly didn’t happen everywhere in the first year.
There’s big money involved in the Medicaid expansion decision for states. Under ACA rules, the federal government pays the vast majority of the cost of covering people who are newly eligible for Medicaid. Through the end of 2016, the federal government fully funded Medicaid expansion. The states started to pay a small fraction of the cost starting in 2017, eventually paying 10 percent by 2020. From there, the 90/10 split is permanent; the federal government will always pay 90 percent of the cost of covering the newly eligible population, assuming the ACA remains in place.
The cost of NOT expanding Medicaid eligibility
Because the federal government funds nearly all of the cost of Medicaid expansion, the 19 states that haven’t yet expanded coverage are missing out on nearly $364 billion in federal funding between 2013 and 2022, if they continue to reject Medicaid expansion. (Indiana, Pennsylvania, Alaska, Montana, and Louisiana have expanded their Medicaid programs since that report was produced in 2014, so they are no longer missing out on federal Medicaid expansion funding.)
Just five states – Florida, Texas, North Carolina, Georgia, and Tennessee – stand to receive nearly 60 percent of that funding (a total of $227.5 billion by 2022) if they expand Medicaid to cover their poorest residents.
For residents of states that haven’t expanded Medicaid, their federal tax dollars are being used to pay for Medicaid expansion in other states, while none of the Medicaid expansion funds are coming back to their own states. From 2013 to 2022, $152 billion in federal taxes will be collected from residents in states not expanding Medicaid, and will be used to fund Medicaid expansion in other states.
Hospitals in states that don’t expand Medicaid are suffering too. Hospitals that treat large numbers of uninsured patients rely on federal funding from Disproportionate Share Hospital (DSH) payments to help cover the cost of the uncompensated care they provide. But DSH payments are being phased out by 2020, because Medicaid expansion was expected to sharply reduce the amount of uncompensated care hospitals must provide. Hospitals in states that have rejected Medicaid expansion will continue to provide a significant amount of uncompensated care, but their funding will be stretched even thinner than it already is.
The human toll of the Medicaid coverage gap
Of course, there’s more to Medicaid expansion than just money. Harold Pollack very clearly explains the human toll of the Medicaid coverage gap: Based on the 3,846,000 people who were expected to be in the coverage gap in January 2015, we can expect 4,633 of them to die in any given year because they don’t have health insurance. (Pollack’s number is higher, because his article was written in May 2014, before New Hampshire and Pennsylvania agreed to expand coverage; Indiana and Alaska also expanded coverage in 2015, and Montana‘s enrollment in Medicaid expansion began in November 2015, for coverage effective January 2016; Louisiana‘s Medicaid expansion took effect in 2016).
There has been a slow but steady push towards Medicaid expansion based on those financial and moral arguments, even in some of the reddest states. And the Supreme Court’s June 2015 ruling in King v. Burwell — which upheld the legality of premium subsidies in states that use the federally run health insurance exchange (Healthcare.gov) — gave new life to Medicaid expansion discussions in states that wanted to utilize Medicaid funds to purchase private health insurance for low-income residents (if the Court had struck down subsidies in states that haven’t created their own exchanges, the private insurance market would likely have destabilized and premiums would have skyrocketed).
Public support for Medicaid expansion
Public support for Medicaid expansion is relatively strong, even in Conservative-leaning states: In Wyoming (considered the most Conservative state), 56 percent of the public are in favor of Medicaid expansion. But the Republican-led legislature in Wyoming has consistently rejected Medicaid expansion, despite Republican Governor Matt Mead’s support for expansion.
In Utah, 88 percent of the state’s residents supported Governor Herbert’s 2014 proposal for Medicaid expansion over the status quo, and public support for providing coverage for people in the Medicaid coverage gap continues to be strong in Utah. Utah enacted a bill in 2018 directing the state to seek federal approval for a partial Medicaid expansion proposal, to expand Medicaid only to 100 percent of the poverty level, instead of 138 percent. That’s unlikely to gain federal approval, but full Medicaid expansion will be on the ballot in Utah in November 2018, bypassing the legislature and governor altogether.
In Texas – home to more than a quarter of those in the coverage gap nationwide – a board of 15 medical professionals appointed by Governor Rick Perry recommended in November 2014 that the state accept federal funding to expand Medicaid, noting that the current uninsured rate in Texas is “unacceptable.” (U.S. census data indicated that 16.6 percent of Texas residents were uninsured in 2016 – the highest rate in the country.) But no real progress towards Medicaid expansion has been made since then.
There are several other states where the legislature or the governor – or both – are generally opposed to the ACA, but where Medicaid expansion has been actively considered, either by the governor or legislature or in negotiations with the federal government. These include Kansas, North Carolina, Tennessee, and Missouri, but thus far, none of those states have enacted legislation to expand Medicaid.
Our Medicaid section provides updated state-by-state information on the current status of Medicaid expansion, along with general information about each state’s program. If you’re curious about what’s going on in your state, check it out.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.